14th Conference on Retroviruses and Opportunistic Infections Los Angeles, California - February 25-28, 2007

Conf Retrovir Opportunistic Infect 2007 Feb 25-28;14: (abstract no. 34)

David Moore^1,2, C Yiannoutsos³, B Musick³, R Downing¹, W Were¹, R Degerman¹, L Alexander¹, and J Mermin^1
1Global AIDS Prgm, CDC Uganda, Entebbe; ²BC Ctr for Excellence in HIV/AIDS, Vancouver, Canada; and ³Indiana Univ Sch of Med, Indianapolis, US

BACKGROUND: Mortality among HIV-infected individuals initiating ART in Sub-Saharan Africa is higher than in industrialized countries. The ability of programs in Africa to design specific interventions to prevent these deaths is limited by a paucity of data on specific clinical conditions that are associated with mortality while taking ART in African settings.

METHODS: We examined data from participants aged ≥18 years in the Home-Based AIDS Care project in Tororo, Uganda, to describe mortality rates over time and to determine clinical conditions associated with death. Survival analysis was used to examine variables at baseline and in follow-up that were associated with mortality while taking ART.

RESULTS: A total of 1120 subjects initiated ART (73% women). Median CD4 cell count at initiation of ART was 127 cells/µL, median hemoglobin was 11.3 g/dL, median body mass index was 19.7 kg/m², and 8% of subjects had WHO stage IV disease. Subjects were followed for a median of 2.0 years. Cumulative mortality was 3.3% during the first 3 months, 5.1% at 6 months, 7.5% at 12 months, 8.6% at 18 months, and 9.3% at 24 months after ART initiation. Tuberculosis (TB) was the most common opportunistic infection associated with death (21% of deaths), followed by cryptococcal disease (11%), candidiasis (11%), Pneumocystis jiroveci pneumonia (9%), and Kaposi’s sarcoma (6%). In 41.5% of deaths, no specific clinical condition was identified and 7% of deaths had ≥2 diseases associated with death. Baseline CD4 cell counts (HR 1.006, 95%CI 1.003 to 1.008), body mass index <18 kg/m² (HR 2.1, 95%CI 1.3 to 3.2), and hemoglobin <10 g/dL (HR 2.6, 95%CI 1.7 to 3.9) were the most important predictors of death in the first 6 months of ART. Adherence to therapy of ≤90% was strongly associated with death in adjusted models and the strength of the association increased from HR 3.3 in the first 6 months (p <0.001) after ART initiation to HR 7.4 after 6 months (p <0.001).

CONCLUSIONS: Strongly associated with mortality while receiving ART are conditions that can be remedied—such as low body mass index and anemia—or prevented—such as TB, candidiasis, and cryptococcal disease. These conditions should be addressed through interventions, such as food supplementation, aggressive treatment of anemia, and specific preventive therapy. Adherence to therapy assumes greater importance with increasing time on ART.

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2007-02-25
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